Hindawi Publishing Corporation

BioMed Research International

Volume 2017, Article ID 4585360, 7 pages
http://dx.doi.org/10.1155/2017/4585360

Research Article
Duodenal Atresia: Open versus MIS Repair—Analysis of Our
Experience over the Last 12 Years

Salvatore Fabio Chiarenza, Valeria Bucci, Maria Luisa Conighi, Elisa Zolpi,
Lorenzo Costa, Lorella Fasoli, and Cosimo Bleve
Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital,
Vicenza, Italy

Correspondence should be addressed to Salvatore Fabio Chiarenza; fabio.chiarenza@ulssvicenza.it and

Cosimo Bleve; cosimo.bleve@ulssvicenza.it
Received 11 November 2016; Revised 30 January 2017; Accepted 31 January 2017; Published 23 February 2017

Academic Editor: Hiroo Uchida

Copyright © 2017 Salvatore Fabio Chiarenza et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Objective. Duodenal atresia (DA) routinely has been corrected by laparotomy and duodenoduodenostomy with excellent long-term
results. We revisited the patients with DA treated in the last 12 years (2004–2016) comparing the open and the minimally invasive
surgical (MIS) approach. Methods. We divided our cohort of patients into two groups. Group 1 included 10 patients with CDO
(2004–09) treated with open procedure: 5, DA; 3, duodenal web; 2, extrinsic obstruction. Three presented with Down’s syndrome
while 3 presented with concomitant malformations. Group 2 included 8 patients (2009–16): 1, web; 5, DA; 2, extrinsic obstruction.
Seven were treated by MIS; 1 was treated by Endoscopy. Three presented with Down’s syndrome; 3 presented with concomitant
malformations. Results. Average operating time was 120 minutes in Group 1 and 190 minutes in Group 2. In MIS Group the
visualization was excellent. We recorded no intraoperative complications, conversions, or anastomotic leakage. Feedings started
on 3–7 postoperative days. Follow-up showed no evidence of stricture or obstruction. In Group 1 feedings started within 10–22
days and we have 1 postoperative obstruction. Conclusions. Laparoscopic repair of DA is one of the most challenging procedures
among pediatric laparoscopic procedures. These patients had a shorter length of hospitalization and more rapid advancement to
full feeding compared to patients undergoing the open approach. Laparoscopic repair of DA could be the preferred technique, safe,
and efficacious, in the hands of experienced surgeons.

1. Introduction may represent an intrinsic or extrinsic obstruction [3]. To

Duodenal atresia (DA) is a fairly common congenital
anomaly occurring in approximately 1 per 5000 to 10000 live
births, affecting boys more commonly than girls. More than
50% of affected patients have associated congenital anoma-
lies: trisomy 21 (approximately 30% of patients), as part of the
VACTERL complex of anomalies (vertebral, anorectal, car-
diac, oesophageal atresia, renal, and limb anomalies); isolated
cardiac defects, 30%; prematurity 45%; growth retardation
33%; other intestinal anomalies, 25% [1, 2].
Typically, the diagnosis is made by prenatal ultrasound
with a history of polyhydramnios (32% to 81%) and the detec-
tion of two fluid-filled structures consistent with a “double
bubble” (the stomach and the dilated proximal duodenum),
in up to 44% of case. The amniotic fluid-filled “double bubble”
confirm duodenal obstruction is important to visualize the
dilated duodenum for several minutes as it is possible that
intestinal peristalsis in a fetus may show transient dilatation
suggesting duodenal obstruction [4]. It is also important to
demonstrate the continuity between the gastric and duodenal
bubbles to exclude other causes. Choudhry et al. (2009) [3]
showed that the prenatal diagnosis was made on prenatal
ultrasound at or earlier than 20 weeks of gestation in keeping
with the previously mentioned literature [3, 5, 6].
At birth, plain abdominal radiograph reveals the classic
double bubble sign with no distal gas [1]. The presentation of
the neonate varies depending on the following: complete or
incomplete obstruction and location of Vater’s ampulla in
relation to the obstruction (postampullary approximately in
85%).
2 BioMed Research International

Table 1: (a) Patients subdivision on surgical approach and type of duodenal atresia/stenosis. (b) Congenital anomalies in the babies
undergoing repair of CDO.

(a)

Type I Type II Type III Extrinsic obstruction

2004–2009 Group 1: open approach (n = 10) 3 — 5 2
2009–2015 Group 2: mininvasive approach (n = 8) 1 — 5 2
(b)

Associated congenital anomalies Open group (1) Mininvasive group (2)

Trisomy 21 3 3
Congenital heart disease — 1
Gastrointestinal disease 3 1
Genitourinary — 1
Airways disease — 1

The first report of surgical correction of DA was by Ladd
in 1931 with a reported mortality of 40% [7]. The traditional
method of repair of DA is an open duodenoduodenostomy in
a diamond-shaped configuration, described by Kimura et al.
in 1990 [8]. This technique has become the standard.
Recent improvements in laparoscopic equipment and
techniques have sparked a revolution in the surgical care of
infants and children. The introduction of advanced laparo-
scopic techniques in the neonate has more recently led to a
new surgical approach, the laparoscopic duodenoduodenos-
tomy [1]. The first reports of laparoscopic repair of duodenal
atresia date 2001 and 2002, when shortly after each other
Bax et al. [9] and Rothenberg [10] described their initial
experience with this approach [11]. Based on our experiences
with MIS approach in neonates to treat other congenital
anomalies, we elected to undertake the evaluation and treat-
ment of patients presenting with duodenal obstruction using
a laparoscopic approach. We revisited the patients with DA
treated in the last 12 years comparing the open and the MIS
approach.
2. Materials and Methods
We conducted a standardized chart review of all records from
our Institution from January 2004 to January 2015. All cases
with a diagnosis of “intestinal atresia” were obtained and then
hand-screened to select only those cases of duodenal atresia
or stenosis. All cases of congenital duodenal obstruction
(CDO) seen in our Institution, Pediatric Minimally Invasive
Surgery and New Technologies of San Bortolo Hospital, in
Vicenza, Italy, were then reviewed.
Data collected included method of diagnosis, associated
anomalies, patient age and weight at surgery, operative
procedures performed, operative time, any intraoperative
complications, and postoperative course.
We divided our patients into two homogeneous groups,
Tables 1(a) and 1(b). Group 1 consisted of 10 patients between
2004 and 2009 treated with an open procedure until the
laparoscopic approach was introduced. Of these patients, 5
had a duodenal atresia (DA), 3 a duodenal web, and 2 an
extrinsic obstruction (an annular pancreas with a complete
obstruction of the lumen and a preduodenal portal vein with
a quite complete obstruction). Three had Down syndrome
and 3 concomitant malformations. Group 2 consisted of 8
patients that underwent operation between 2009 and 2015
(December 2014). These patients were treated with MIS
approach: 7 had laparoscopic procedure performed with
3 mm instruments and 1 had endoscopic web resection.
This group included 5 DA, 1 duodenal web, and 2 extrinsic
obstructions (both presented an annular pancreas with a
complete obstruction of the lumen). Three patients had Down
syndrome and 3 concomitant malformations.
The operating room set-up is represented in Figure 1.
The surgeon stands at the foot of the table, the first assis-
tant/camera operator is at the foot of the table on the patient’s
left side to allow the surgeon performance while the scrub
nurse stands on the patients right side. The monitor is
positioned at the head right side of the patients while the
anaesthesiologist stands at the head of the table on the left
side. With the patient in the supine/semilateral position,
general anesthesia is induced. The abdomen is prepared and
draped in the usual sterile fashion.
The procedure began with umbilical scar incision. The
dissection was carried out down through the subcutaneous
tissues (open access), and the umbilical arteries and vein are
dissected free and ligated. Under direct vision, a 5 mm port is
placed into the peritoneal cavity. The abdomen is insufflated
with carbon dioxide (5–7 mmHg, 2 l/min) and a 30∘ angle
telescope is placed into the abdominal cavity, which is then
inspected for additional anomalies (malrotation or intestinal
atresia).
Then, two additional 3 mm trocars for 3 mm instruments
were inserted under direct vision in the lower right and
left quadrant. An additional 3 mm grasping forceps can be
introduced in the left epigastric quadrant for lifting the liver.
A personal trick consists in positioning a transcutaneous
traction suture around the hepatic falciform ligament to
lift up the liver avoiding the need of the 3 accessory port,
Figure 2. In this way, we gain access to the area of the
bulbus duodeni. The transverse colon (gastrocolic ligament)
is partially dissected from the stomach and duodenum and
reflected inferiorly. The duodenum is then mobilized from its
BioMed Research International
Figure 1: Operatory room set-up.
Figure 2: Traction suture on proximal dilated duodenum through
the superior portion of this segment (serosal layer) to expose
correctly the inferior surface.
retroperitoneal position and the dilated proximal duodenal
atresic end is identified. At this point, we introduce one
stay suture transcutaneously through the superior portion of
this segment (serosal layer) to expose correctly the inferior
surface making a transverse incision, Figure 3. The second
and third portions of the duodenum are adequately mobilized
using a “no touch” technique as much as possible to allow a
tension-free diamond-shaped duodenoduodenostomy.
If there are some doubts regarding the incomplete atresia
(internal duodenal web) we introduce and gently push a naso-
gastric tube down toward the distal part of the duodenum to
check a possible internal obstruction. In this case pushing the
tube we can clearly detect an incisure on the duodenal surface.
The second surgical step is to incise distal duodenum lon-
gitudinally with scissors and open the bulbus at a convenient
place transversely for easy anastomosis, Figures 4(a) and 4(b).
In case of internal obstruction a longitudinal incision along
the proximal delineated insertion of the web is performed
down to the distal duodenum and the occlusive membrane
is excised.
The third step is to start making the diamond-shape
anastomosis from the distal end of the distal duodenum
halfway down the lower end of the bulbus with standing
Vicryl 5/0 sutures. From there the anastomosis is continued
distally toward the distal corner of the bulbus and then
forward toward the proximal corner of the bulbus.
3
Figure 3: Transverse incision of proximal duodenum.
The nasoduodenal tube previously inserted is pulled
through the anastomosis under vision and in case of doubts
of distal obstruction saline is injected to test the canalization;
finally, the ventral part of the anastomosis is laid to complete
it, Figures 5(a) and 5(b). In Group 1 all the duodenoduo-
denostomies were performed with single interrupted stitches.
In Group 2 we use either separate two running sutures for
the posterior or anterior wall or single interrupted stitches
without differences in the results. The choice of the suture was
made considering the size of the surgical field in which we
have performed the duodenal anastomoses trying to use
the most ergonomic technique. In three cases we used an
interrupted suture while in four we used two running sutures
for the posterior or anterior wall of the duodenum. The colon
is laid back over the duodenum and the trocars are removed
under direct vision.
3. Results and Discussion
The demographics of the two groups were comparable.
Patients median weight was 2742 g in Group 1 and 2495 g in
Group 2. There was a prenatal diagnosis in both groups based
on polyhydramnios and the detection of the double bubble
sign, except for 3 patients in Group 1 and 1 in Group 2 who
presented a prenatal diagnosis for oesophageal atresia. The
male/female ratio was 3/7 in Open Group and 2/6 in MIS
Group. The mean age was 36 weeks for both. The obstruction
was preampullary in 9/10 patients in the Group 1 and in all 8
patients of Group 2. Multiple associated anomalies were
seen in our patients including trisomy 21, cardiac anoma-
lies, anorectal malformations (cloaca), pancreatic anomalies,
laryngeal stenosis, and other intestinal malformations as
oesophageal atresia and malrotation. Trisomy 21 was the most
common anomaly, found in 6 of our patients (33%). Four
patients were born prematurely (25%).
Most of our patients underwent surgery during the
first week of life (Group 1 range: 1–26 days; Group 2: 1–4
days). All patients in both groups with intrinsic and extrin-
sic obstruction underwent diamond-shaped duodenoduo-
denostomy except the patient with duodenal web in Group
2 who was treated with endoscopic excision of the web.
Hospital stay was 25 days for the Open Group and of 13-14
4 BioMed Research International

(a) (b)

Figure 4: (a) Distal atresic duodenum; (b) longitudinal incision of superior surface of distal duodenum.

(a) (b)

Figure 5: Diamond-shape anastomosis. (a) A nasoduodenal tube is inserted and pulled through the anastomosis under vision. (b) Completed
anastomosis.

days for the MIS Group. The canalization was registered after
an average of 8–12 days in Group 1 and 3 days in Group 2.
Time to initiation of feeds averaged 3–5 days for laparoscopic
procedures and 10–22 days for open procedures and time to
full feeds averaged 7–9 days and 15–25 days, respectively.
A transanastomotic-tube was left in all patients of Group
1. It was used to start feeding and removed after 10–22 days
(time to initiation of feeds). In Group 2 the nasoduodenal
tube previously inserted is pulled through the anastomosis
under vision and after the ventral part of the anastomosis
was completed it was retired and positioned in the stomach
(nasogastric tube). Only in the first patients was it used as
TAT. In this case it was retired after 5 days and used as
nasogastric tube. In Group 2 as in the Open one the tube
was used for feeding. We did not record a delay in gastric
emptying due to occlusion of the lumen in MIS Group
patient. In Group 1 we had recorded a longer time to initial
feeding and time to full oral intake with a slower reduction of
daily volume of the fluid returned from the nasogastric (NG)
tube which was bilious in the first days.
In MIS Group all cases were completed laparoscopically,
and there were no intraoperative complications. The laparo-
scopic procedures were performed by the senior surgeon and
there were no postoperative leaks, no missed distal intestinal
obstructions, and no short-term/long-term complications.
Postoperative UGI has been obtained in all cases.
In Group 1 (Open) malrotation was found in 2 patients
and cloaca in another one; in Group 2 (MIS) we did not find
malrotation, and we had oesophageal atresia associated as
gastrointestinal malformation in one patients. With malro-
tation Ladd’s procedure was performed without particular
difficulty. In these series we did not perform Ladd’s procedure
laparoscopically, but we have experience in our centre of this
procedure in mininvasive surgery.
Comparing the two groups average operating time was
120 min in Group 1 and 180–240 min in Group 2. Operative
time obtained was that recorded by the scrub nurse and
anaesthesiologist from initial operative start time to final skin
closure. Detailed data on operative time for the laparoscopic
duodenoduodenostomy alone (i.e., excluding time for addi-
tional procedures) were not available in all cases. The length
of postoperative hospitalization, time to initial feeding, and
time to full oral intake were all statistically shorter in patients
undergoing a laparoscopic repair, Table 2.
Newborn and infants may require a laparotomy for a wide
variety of intra-abdominal conditions. Surgeons traditionally
BioMed Research International
Table 2: Main outcome variables in the babies undergoing repair of
CDO.
Open approach Mininvasive
Outcome Variable
(𝑁 = 10) approach (𝑁 = 8)
Operative time 120 min 180–240 min
Length of
postoperative 25 days 12–14 days
hospitalization
Canalization 8–12 days 3 days
Time to initial feeding 10–22 days 3–5 days
Time to full oral
15–25 days 7–9 days
intake
UGI studies 8–15 days 4–7 days
Evidence of stricture 1 —
Leakage — —
have used open approach to address these conditions, but
recent advances in mininvasive surgical techniques have
kindled an interest in a minimally invasive approach to a
wide variety of abdominal pathologies. These laparoscopic
procedures have been shown to be technically possible,
equally efficacious, and cosmetically superior.
Duodenal obstruction, such as that resulting from atresia
or web, is one of these conditions which routinely has been
corrected by laparotomy and duodenoduodenostomy. Atresia
is classified into intrinsic and extrinsic form. The intrinsic
atresia includes the following (Gray and Skandalakis): Type
I (92%) with a web formed by mucosa and submucosa and
an intact mesentery; this type includes the possible variant of
windsock deformity (the membrane is thin and elongated);
Type II (1%): two blind ends of duodenum connected by
a fibrous short cord with intact mesentery; Type III (7%):
the 2 blind ends being completely separated with a V-
shaped mesentery defect. The extrinsic forms are prevalently
represented by annular pancreas and Ladd’s bands.
The first report of surgical correction of DA was by
Ladd in 1931 with a reported mortality of 40% [7]. Over
the last decades the improvements in operative techniques
and postoperative care and the advancements in neona-
tal intensive care, parenteral nutrition, and management
of associated anomalies have reduced mortality to 5–10%,
related mostly to important heart malformations [1]. Several
techniques have been described for the repair of duodenal
atresia. Prior to the mid-1970s duodenojejunostomy was the
preferred technique followed by side-to-side duodenoduo-
denostomy, partial web resection with Heineke-Mikulicz type
duodenoplasty, and tapering duodenoplasty. The diamond-
shaped duodenoduodenostomy described by Kimura et al. in
1990 [8] has become the standard. Recent improvements in
laparoscopic equipment and techniques have sparked a rev-
olution in the surgical care of infants and children. The
introduction of advanced laparoscopic techniques in the
neonate has more recently led to a new surgical approach, the
laparoscopic duodenoduodenostomy [1]. The first reports of
laparoscopic repair of duodenal atresia date 2001 and 2002,
when shortly after each other Bax et al. [9] and Rothenberg
[10] described their initial experience with this approach
5
[11]. We revisited the patients with DA treated in the last 10
years comparing the open and the minimally invasive (MIS)
approach describing our early experience with laparoscopic
duodenoduodenostomy.
The application of MIS for the correction of congenital
anomalies has increased significantly over the last years.
The ability to perform delicate dissection and intracorporeal
anastomosis has enlarged the scope of entities that can be
approached. Although most neonatal conditions present-
ing with bowel obstruction present a difficult problem for
laparoscopy because of the dilated bowel and limited abdom-
inal cavity, this is not the case in duodenal atresia. In these
patients, the entire small and large bowel are decompressed,
allowing for excellent workspace even in low birth babies
(according to our surgical experience with neonatal MIS
approach) and there is an excellent exposure of the proximal
duodenum. The laparoscope helps achieve a magnification
of the operatory intra-abdominal field and consequently
an accurate anastomosis even in bowel with a diameter of
less than 5 mm [12]. The lack of distal bowel manipulation
and probably the most declivous anastomosis seems to
result in a shorter ileus and earlier initiation of feeds as
described in a recent report by Spilde et al. [13]. They
compared the laparoscopic and open approach to congenital
duodenal obstruction and showed significantly shorter time
to initiation of feeds, time to full feeds, and postoperative
hospitalization in their laparoscopic group.
According to our experience (not only limited to neonate
with CDO) and regarding patient outcomes, we found that
the laparoscopic approach for CDO repair resulted in sig-
nificantly shorter postoperative hospitalization, shorter time
to initial feeding, and a shorter time to full oral intake.
Comparing laparoscopic and open procedures (as suggested
by multiple authors) these reductions may be attributed to
less inhibition of bowel function and an abbreviated ileus
related to the laparoscopic approach when compared to the
open operation [13, 14]. We also recorded in MIS Group,
compared with Open Group, a faster reduction of daily
volume of the fluid returned from the nasogastric (NG) tube,
which was no longer bilious in nature. We considered this
sign a direct indication of an abbreviated ileus. Moreover, the
postoperative UGI contrast studies, used routinely to evaluate
for anastomotic leaks, help in this management leading us
to remove the NG tubes after the contrast study showing no
leak and contrast progression through the anastomosis. In
this report, the mean time to NG tube removal for the
laparoscopic group was 5 days with initial feeding start at
6–12 hours later. However, the latest cases treated showed
an anticipation of the beginning of nutrition in the third
postoperative day, also before the radiological study.
One reported disadvantage of the laparoscopic approach,
as described in the reports following the first of Rothenberg in
2002, was the postoperative leak rate after conventional sutur-
ing techniques, considered unacceptable. For this reason,
the U-clips were introduced to perform the anastomosis
laparoscopically [1, 2]. All of our cases, 7 have been performed
as described also by Kay et al. [1] with conventional suturing
techniques without any observed leaks using both a running
and interrupted suture line without complication. During
6 BioMed Research International
Figure 6: Endoscopic resection of duodenal web.
the procedure we mobilize the second and third portions
of the duodenum adequately using a “no touch” technique
as much as possible to allow a tension-free diamond-shaped
duodenoduodenostomy, reducing the risk of leakage.
In our series, we included one patient with a clear duode-
nal web (associated with oesophageal atresia). In this patient,
the diagnosis of duodenal obstruction was delayed after
thoracoscopic repair of oesophageal atresia and underwent
endoscopic resection of the web [15], Figure 6.
Another possible disadvantage of mininvasive approach
is the difficult evaluation of the distal bowel to diagnose
other associated intestinal atresia. During open procedures
traditionally it is mandatory to inspect visually the bowel for
distal atresic/obstructed segment. In this way, internal webs
are more difficult to see. When the doubt of a web is high, the
practice is to infuse the bowel with saline solution to confirm
or not the obstruction. What we can affirm, according to
what is described by other reports, is that despite the reduced
possibility of detecting distal atresia (extremely low, <2%)
[3, 16, 17], if time is taken laparoscopically to run the bowel,
which is decompressed, only Type I atresia (web) could be
missed. To infuse the bowel with saline is more difficult to
perform laparoscopically (we do not perform it routinely)
but we considered that the advantages of MIS approach are
greater and more significant than this small risk. In our study
we in both the laparoscopic and open approaches we did
not record any incidence of bleeding, need of conversions
or leakage; only one case of stricture formation in Open
Group. The follow-up of our series for laparoscopic group
ranges from 6 years to 6 months. This group, according
to us, does not represent a large series, but the rarity of
congenital anomaly (CDO) is such that allows us to affirm
the effectiveness of laparoscopic procedure despite reports
which described high leakage rate and other complications.
Our results suggest that laparoscopic duodenoduodenostomy
is safe and effective in surgeons with adequate laparoscopic
skills.
4. Conclusions
Nowadays the prognosis for patient with CDO is excellent.
Laparoscopic repair of duodenal atresia is a very elegant
technique to restore continuity of the duodenum. The patient
seems to benefit from the laparoscopic approach, for quick
recovery and early oral refeeding, which lead to a fast return
to full oral nutrition and discharge, as we show in this
series, comparing with the traditional approach. According to
our experience, the bowel with this approach is exposed to
fewer risks deriving from its exteriorization, exposure, and
hydroelectrolytic losses and in terms of manipulation. In
summary, our experience demonstrates that laparoscopic
duodenoduodenostomy can be performed safely and success-
fully even in the neonate with excellent short-term outcomes.
Obviously, what is possible to conclude by a revision of
the reports of the literature and by our direct experience
is that conditions (CDO and DA, like OA) required a very
experienced pediatric endoscopic surgical group (composed
of surgeon, anaesthesiologist, pediatrician, and nurse) with a
high level of expertise.
Competing Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
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